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Infant feeding practices among mildly wasted children: a retrospective study on Nias Island, Indonesia

Infant feeding practices among mildly wasted children: a retrospective study on Nias Island,... Background: This study investigated the infant feeding practices of participating mothers who were recruited into a research project aimed at improving the nutritional status of mildly wasted children (< -1.0 to ≥ -1.5 Weight-for- Height Z-scores) aged ≥ 6 to < 60 months on Nias Island, Indonesia. Methods: Cross-sectional, questionnaire-based interview of mothers of the index children (n = 215) who were admitted to the community program for mildly wasted children in the study area. Four focus groups and twenty in-depth interviews were conducted to explore further information on infant feeding practices in the study area. Results: Retrospective results indicated that 6% of the mothers never breastfed. Fifty two percent of mothers initiated breastfeeding within six hours of birth, but 17% discarded colostrum. Exclusive breastfeeding until 6 months of age was practiced by 12%. Seventy-four percent of the mothers offered supplementary liquids besides breast milk within the first 7 days of life, and 14% of infants received these supplementary liquids from 7 days onwards until 6 months of age. Moreover, 79% of the infants were given complementary foods (solid, semi-solid, or soft foods) before 6 months of age. About 9% of the children were breastfed at least two years. Less than one in five of the mildly wasted children (19%) were breastfed on admission to the community program. Qualitative assessments found that inappropriate infant feeding practices were strongly influenced by traditional beliefs of the mothers and paternal grandmothers in the study areas. Conclusion: Generally, suboptimal infant feeding was widely practiced among mothers of mildly wasted children in the study area on Nias Island, Indonesia. To promote breastfeeding practices among mothers on Nias Island, appropriate nutrition training for community workers and health-nutrition officers is needed to improve relevant counseling skills. In addition, encouraging public nutrition education that promotes breastfeeding, taking into account social-cultural factors such as the influence of paternal grandmothers on infant feeding practice, is needed. Keywords: Breastfeeding, Complementary foods, Infant feeding, Wasted children, Nias Island Background in communities around the world [1-5]. Nationwide data Delayed breastfeeding initiation, colostrum deprivation, in Indonesia has shown that only 39% of infants experi- supplementary feeding of breast milk substitutes, early ence early initiation of breastfeeding (within one hour introduction of complementary feeding, and incorrect after birth) and 32% are exclusively breastfed for less weaning from breast milk are commonly found practices than six months [6]. Seventy-five percent of children aged 6 to 9 months were continuing to be breastfed and received complementary foods [6]. A prior survey by the * Correspondence: [email protected] Church World Service (CWS) on Nias Island, North Institute for Social Sciences in Agriculture, Center Gender and Nutrition (430b), University Hohenheim, Fruwirthstrasse 14-16, 70593 Stuttgart, Sumatra Province documented that solid foods were Germany introduced as early as 3 months and appropriate Full list of author information is available at the end of the article © 2012 Inayati et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 2 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 breastfeeding practices were uncommon (CWS Indone- or milk from a wet nurse) and nothing else, not even sia unpublished report). water, with the exception of prescribed medicines and It is well known that breastfeeding influences a child’s vitamin supplements [12]. Timely breastfeeding initia- health positively and improves nutritional status [7-9]. A tion is referred to as the start of breastfeeding within meta-analysis from three developing countries showed one hour after delivery [12]. The discontinuation of that infants who were not breastfed had a six-fold breastfeeding before six months is defined as ‘early’ dis- greater risk of dying from infectious diseases within the continuation of breastfeeding according to the breast- first two months of life than those who were breastfed feeding recommendations of the Ministry of Health, [10]. Six months of exclusive breastfeeding and contin- Republic of Indonesia. ued breastfeeding in the first year of life could also pre- vent 1.3 million child deaths worldwide according to Data collection systematic reviews from the Bellagio Child Survival The structured questionnaire used for interviewing was Study Group [11]. In addition, incorrect infant feeding pre-tested for cultural sensitivity before data collection. practices pose significant risks for malnutrition among The questionnaire forms were completed during face- children under the age of five [1,12,13]. to-face interviews with the mothers. Data collected To date, no data has been collected describing the included demographic and anthropometric variables, infant feeding patterns among mothers of mildly wasted infant feeding practices and history. children on Nias Island. This Nias study tried to assess Qualitative data assessments were performed to the history of infant feeding practices among respon- explore further information on infant feeding practices dents who were recruited into the community program in the study area. The data were collected in the course for mildly wasted children on Nias Island. In addition, of four focus group interviews, and during individual in- the study tried to determine the need for enhanced edu- depth interviews. Focus group interviews were con- cational intervention to improve the infant feeding situa- ducted in four villages in the study area (n =23).In tion there. Data were collected via a structured addition, twenty in-depth interviews were done with questionnaire that was completed in face-to-face inter- selected caregivers whose children were recruited into views as well as in focus group discussions. the study. A structured questionnaire was pre-tested prior to the study to improve comprehension. To over- Methods come the possible cultural, literacy, and language bar- Study setting and population riers, one experienced health and nutrition officer of the The study was conducted from October 2007 to Sep- implementing partner (with similar ethnicity) was pre- sent during the qualitative data assessments. With tember 2008 in the Church World Service (CWS) pro- ject area in Gunung Sitoli, Sirombu, and Mandrehe respect to focus group interviews, the moderators were Districts, Nias Island, North Sumatra Province, Indone- trained in data collection techniques prior to the quali- sia. A total of 215 mothers of mildly wasted children (< tative data assessments. -1.0 to ≥ -1.5 Weight-for-Height-Z-scores, according to WHO/NCHS reference data [14]) aged ≥ 6to< 60 Data analysis months participated in the study, which aimed at Data were coded and analyzed using the PASW/SPSS improving the nutritional status of children under five package version 19.0 (SPSS Inc., Chicago, IL, USA). years of age in this community [15]. Values were presented in percentages and means (± All mothers were interviewed at admission and were standard deviation). Qualitative data was audio taped informed about the purpose of the study. The interviews and transcribed verbatim by an experienced transcriber. were conducted by health-nutrition officers of the Interviewers and researchers reviewed the transcripts at implementing partners (CWS) who had attended a two- leastoncetoconfirm theaccuracyof the transcribed day practical training course on interview skills prior to statements. The data were further evaluated via thematic the actual data collection. Informed consent was sought analysis and coded for themes. prior to the interview, following the protocols set by the 1995 Helsinki Declaration, as revised in Edinburgh 2000. Results The study was approved by the Ethical Committee of Socio-demographic characteristics the Faculty of Medicine, University of Brawijaya (Nr. 25/ Two hundred and fifteen mothers and their children, PEPK/VIII/2007). assessed as mildly wasted, were eligible for further ana- lysis. Table 1 shows selected socio-demographic charac- Breastfeeding definitions teristics of the study population. Of 215 eligible Exclusive breastfeeding is defined as an infant being fed children, approximately 44% of those admitted to the solely breast milk (including his mother’s expressed milk study were girls. The highest proportion (28%) of them Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 3 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 Table 1 Selected characteristics of the study population The practice of giving early supplementary liquids was on Nias Island (n = 215) also frequently found in the study area. Seventy-four Frequency percent of mothers reported that they introduced liquid (%) foods besides breast milk to their infants during the first Female children, n (%) 95 (44.2) seven days of life (data not shown). Another 14% of Age group (months), n (%) infants were introduced to supplementary liquids 6 - < 12 13 (6.0) between ≥ 8 days and < 6 months. Infant formula (32%) ≥ 12 - < 24 40 (18.6) and tea (26%) were the preferred supplementary liquids ≥ 24 - < 36 61 (28.4) mentioned by the mothers in the study area. ≥ 36 - < 48 42 (19.5) Although WHO/UNICEF recommends exclusive ≥ 48-60 59 (27.4) breastfeeding for the first six months of life, only 12% of Weight-for-Height-z-score (mean ± SD) -1.3 ± 0.1 mildly wasted children (n = 25) in the study area were Height-for Age-z-score (mean ± SD) -1.5 ± 1.5 exclusively breastfed during the first six months of their Weight-for-Age-z-score (mean ± SD) -1.9 ± 0.8 lives. Age group (< 30 y), n (%) Seventy-nine percent (n = 169) of the mothers intro- Mothers 140 (65.1) duced complementary foods (solid, semi-solid or soft Fathers 89 (41.4) foods) earlier than the international recommendation of Occupation (farmer), n(%) 6 months (Figure 2). One hundred and forty-four out of Mothers 149 (69.3) 215 caregivers (67%) had already introduced comple- Fathers 122 (56.7) mentary foods before the children were four months Education of caregiver (≥ 6y), n(%) old. Five percent of the respondents (n = 10) even Mothers 80 (37.2) offered complementary foods when the children were Fathers 123 (57.2) less than one month old. Only 12% of the mothers Paternal grandmothers 99 (46.0) introduced complementary foods to their children after Household asset: ownership of TV, n(%) 54 (25.1) six months of age. Rice porridge (n = 138), milk por- Time use for income generating activities (mean ± 6.4 ± 2.6 ridge (n = 31), boiled steamed rice (n = 30), fruits (n = SD) 7), and commercially prepared baby foods (n =6)were Time use for child caring (mean ± SD) 2.1 ± 1.3 commonly reported as the first foods given to the babies in the study area. was found to be between ≥ 24 to < 36 months. The With respect to the reported duration of breastfeed- ing, most mothers (30%) breastfed their children for a average Weight-for-Height (WHZ) score was -1.3 ± 0.1, total of 6 to 12 months (n = 49), followed by 25% and whereas the average Height-for-Age(HAZ) scorewas 24% who breastfed for ≥ 4 and < 6 months and ≥ 12 -1.5 ± 1.5 and Weight-for-Age (WAZ) was -1.9 ± 0.8. and < 24 months respectively. Thirteen mothers stopped Themajorityofthe mothers(65%) were under30 breastfeeding before the babies were four months old, years old, had less than six years of schooling (63%), and but we also found that 16 respondents continued breast- worked mainly as farmers (69%). Mothers were involved feeding for more than two years (Table 2). in income generating activities for an average of six hours per day, while two hours were dedicated to child care activities. Discussion All families selected for analysis comprised two-parent Breastfeeding initiation households. More than 40% of the fathers were < 30 In our study on Nias, we found that more than half of years and worked in the agricultural sector (57%). the mothers (52%) initiated breastfeeding (la femenu)in Fathers had the best educational level (57% of them the first hour after delivery. In total, 72% of the mothers went to school for more than six years), followed by breastfed their newborns in the first six hours after paternal grandmothers (46%), and mothers (37%). baby’s birth This finding is in line with previous studies The majority of respondent households did not have a in Timor Leste, India, and Turkey [16-18]. However, television (75%). 28% of the Nias mothers initiated breastfeeding six hours after birth or even later, and 17% discarded the Infant feeding practices at admission time colostrum due to local traditional beliefs similar to the Almost 48% of the mothers did not start to breastfeed ones in the study in India [19,20]. Reasons given for not their babies within the first hour after delivery, as feeding colostrum to newborns included the traditional recommended by WHO/UNICEF. However, the major- belief that colostrum was “dirty (n = 24), cheesy (n = ity of respondents (72%) initiated breastfeeding within 14), and indigestible (n =8)” and that “children will suf- the first six hours after birth (Figure 1). fer from stomach ache/afökhö talu (n = 21)”, “children Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 4 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 Figure 1 Time of breastfeeding initiation after birth among respondents Six percent (n = 12) of the children were not breastfed at all. According to the mothers, reasons for not offering breast milk to their children immediately after delivery included “the breast milk did not come out due to inverted nipples (n =4)”, “mother was suffering from sore nipples after childbirth (n =2)”, “child did not want to suck the nipples (n =4)”, and “mother was sick after childbirth (n =2)”. As a substitute for colostrum, mothers gave infant formula (n = 4), sugar water (n = 7) or sweet tea (n = 1) after childbirth. In addition to feeding breast milk substitutes, these mothers introduced complementary foods very early (≤ 1 month of age) will get illnesses such as fever/mofa’aukhu (n = 15)”, and mature milk was believed to be ‘clean’ maternal milk. “children will be stupid/bodo (n =4)”. Colostrum was considered by some mothers to be The notion that “colostrum is dirty” (n = 24) is likely ‘cheesy (oŵoyu)’ breast milk that had been produced late due to the yellowish color of colostrum that is much in the mother’s pregnancy (n = 14) and had no nutri- different from the whitish color of mature mother’s tional value (n = 10). Colostrum was also believed to milk. The yellow color of colostrum was identified with have a bitter taste/afeto (n = 12). Thus several mothers ‘dirty (ta’unö)’ breast milk, while the white color of considered colostrum to be an inappropriate food for Figure 2 Age of introducing solid, semi-solid or soft foods among mothers of mildly wasted children (n = 215) To determine the point prevalence of breastfeeding, mothers were asked whether they had still been breastfeeding their children in the last 24 hours before admission (Table 2). The majority of children in the study area were no longer breastfed at the time of admission (76%). The main reasons for discontinuing breastfeeding included: child was too old to be breastfed, breast refusal, a new pregnancy, infant or maternal illness, as well as decreased breast milk production. Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 5 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 Table 2 Breastfeeding prevalence at admission time (n = 37) and infant formula (n = 25) were the two most among mothers of mildly wasted children (n = 215) preferred pre-lacteal liquids mentioned by the mothers. n = 215 Several mothers believed that providing pre-lacteal liquids couldhelpthe newborns to resisthunger (n = Continuing breastfeeding, n (%) 40 (18.6%) 30). They perceived that because of the process of child- Age of children (months) birth, the newborns experience fatigue, which then leads ≥ 6 - < 12 5 out of 13 to feelings of hunger. Therefore, supplementary feeding ≥ 12 - < 24 17 out of 40 serves the perception that this practice reduces infants’ ≥ 24 - < 60 18 out of hunger in the first hours of their life. Stopped breastfeeding, n (%) 163 (75.8%) Although colostrum is enough to sustain the nutri- tional needs of newborn babies without any additional Reported duration of breastfeeding practice in months n n = 163 (%) foods [12], this concept was not widely known in the < 4 13 (7.8%) study area. Giving pre-lacteal foods (e.g. formula milk or ≥ 4 - < 6 41 (25.2%) anything else other than breast milk) delays the produc- ≥ 6 - < 12 49 (30.1%) tion of breast milk [25,26]. If infants consume pre-lac- ≥ 12 - < 24 39 (23.9%) teal foods or supplementary foods, this interferes with ≥ 24 16 (9.9%) suckling at the breast, the release of prolactin and, ulti- Did not remember breastfeeding duration 5 (3.1%) mately, the production of the mother’s milk [12]. This Never breastfed, n (%) 12 (5.6%) leads to lower breast milk production and a shorter per- iod of breastfeeding [27,28]. Pre-lacteal foods are often a source of newborn infections and diarrhea [12,17]. The the newborn and believed it would be harmful to the delay of breastfeeding initiation and giving pre-lacteal infant’s health. feeds creates a vicious cycle. The practice of pre-lacteal feeding delays the initiation of breastfeeding and the “According to my mother-in-law and other senior delay in initiating breastfeeding promotes further pre- female relatives, colostrum is not a healthy food for lacteal feeding. the newborns. This first milk is dirty and cheesy. If it This Nias study found that three out of four children is given to the newborn, my infant will suffer from received supplementary feeding (liquids) in the first stomach ache . . .” (Mother in Bawadesolo) seven days of their lives. The common reason for giving supplementary feeding in the study area was perceived breast milk insufficiency (n = 22), which was likely due The practice of discarding colostrum is strongly to the delay of breastfeeding initiation. Bearing in mind rooted in the study area. We argue that the strong role that the frequency and the duration of breastfeeding are of senior family members, particularly senior women important factors in stimulating breast milk production, such as the paternal grandmother, in prohibiting the it is not surprising that incorrect breastfeeding practice consumption of colostrum for newborns has sustained such as providing supplementary foods results in insuffi- this custom, and that it has been carried out for genera- cient production of breast milk. tions in the study area. It is known that early initiation of breastfeeding will Introduction of complementary foods (solid, semi-solid or result in better establishment of breastfeeding practices, soft foods) including longer duration of breastfeeding. This practice The appropriate time for introducing complementary also ensures that newborns receive food with high nutri- foods and the types of foods are crucial factors to be tional value at the beginning of their lives. Early breast- feeding initiation can protect the newborn from considered in appropriate infant and child feeding prac- potentially harmful pre-lacteal feeding practices which tices. According to Agudo et al. [4], findings from sev- deprive the infant of the important immune-protective eral studies showed that the majority of mothers in properties of colostrum [12]. developing countries initiated complementary feeding too early. Other studies have had similar findings Practice of pre-lacteal feeding and use of supplementary [29-31]. Our study also revealed that early introduction liquids of solid and semi-solid foods was common in the study Wide use of pre-lacteal foods has been identified from area. previous studies in India, Ethiopia, Bangladesh, and Tan- Most of our respondents preferred to introduce com- zania [17,20-24]. The practice of pre-lacteal feeding was plementary foods (solid, semi-solid, or soft food) when also common in our study area (personal information the children were one to four months old. This was in with Health and Nutrition officers CWS). Sugar water line with the results of our qualitative assessments that Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 6 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 found that the majority of mothers believed that an supplementary food in addition to breastfeeding within appropriate time for introducing complementary foods six months (13%), or to fully replace breast milk (2%) in was between one and four months (n = 32). the study area. Some mothers perceived that infant for- A perceived decline in the production of breast milk mula had highly valuable nutrients that were as good as, was the main reason mentioned for early introduction of or even better than breast milk (n =10).Therefore,they complementary foods in the study area (n =30).Practice believed that if the household had the financial means, of pre-lacteal feeding, skepticism about the sufficiency of formula should be provided to the babies. However, their own breast milk production, inappropriate time of according to Gribble et al. [32] and Mulder-Baalbergen et introduction of complementary foods, as well as infre- al. [33], several considerations should be taken into quent and too short duration of breastfeeds, were appar- account when providing infant formula at the household ently responsible for the decline in the maternal milk level, particularly in emergency situations. These include supply. On the other hand, perceived insufficient breast the availability of clean water, energy for heating/boiling milk production also led to too early initiation of comple- water and sterilizing bottles and other equipment, house- mentary feeding. In both situations, mothers believed hold finances as well as the ability of caregivers to pre- that their child’s crying was a signal of insufficient food pare infant formula correctly according to the intake. Thus, the provision of complementary foods manufacturer’s instruction [32,33]. These requirements seemed to them to be the only way to satisfy the child. appeared to be very difficult for respondents in our study area to meet. “Mothers in this area have usually introduced com- As stated in WHO/FAO guidelines [34], preparing plementary foods when infants are four months old. infant formula according to the manufacturer’sinstruc- However, they will provide complementary foods ear- tions is still not sufficient and safe because of the inherent lier if the child still cries although breast milk has bacterial contamination in many powdered formulas. already been given” (Mother in Tugala Gawu) Manufacturers do not usually give accurate information about an adequate temperature for the water to be mixed The opinions of senior female members of the family, with the powdered formula. In order to destroy the bac- especially the paternal grandmother (ina matua), about teria, water must be boiled and then cooled to no less than the infant’s well-being played an important role in the 70°c (between 70° and 90°C) before mixing. This was also decision of mothers to introduce solid, semi-solid, or soft not known in the study area. Accurate assessment of foods (n = 23). If an infant was considered by the female water temperature is also highly uncertain. in-law to be too ‘thin’ (afuo), a mother was likely to initi- ate complementary foods. As reported by respondents, Exclusive breastfeeding practice the decision to provide complementary foods was usually In our study area, only one out of nine mothers prac- ticed exclusive breastfeeding with their infants. This low not accompanied by maintaining breastfeeding fre- prevalence of exclusive breastfeeding has been com- quency. It is therefore not surprising that increasing sup- monly reported in studies in India, Bangladesh, Sri plemental food was associated with less breastfeeding Lanka, Turkey, and Tanzania [18,20,23,24,30]. Based on and breast milk production declined. Even worse, breast- qualitative assessment, the most common barrier to feeding was generally no longer practiced after a child practicing exclusive breastfeeding in the study area was was given complementary foods. This is a very common perceived insufficient breast milk production (n =30). pattern around the world reflecting a misunderstanding Other reasons, such as believing that the child was star- of complementary feeding (solids) as a replacement for ving (n = 15), the mother’s activity outside her home (n breastfeeding, rather than a complement to it. = 10), poor knowledge of the benefits of exclusive Early introduction of liquids and solids is unnecessary breastfeeding (n = 7), and the mother’s illness (n =7) and unwise because it can reduce the duration and fre- were also mentioned by several mothers. quency of breastfeeding [12,24], as previously observed in A mother may make a decision to add supplemental our study area. Premature introduction of complemen- fluids or soft complementary foods at too early an age if tary foods increases the risk of infant morbidity and mor- she is feeling discouraged about her milk production. If tality [12,24]. We therefore conclude that children in our a mother believes that she cannot produce a sufficient Nias studyareafaceincreased andunnecessaryhealth quantity of breast milk, she tends to decrease her breast- risks due to inappropriate infant feeding practices. feeding frequency. This will result in decreasing breast milk production. The use of infant formula Commercially produced infant formula was provided as a “IamsurethatIdid nothavesufficientbreastmilk supplementary food (liquid) in addition to breast milk production. My breast is too small and I am too thin during the first seven days of life (32%), as a Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 7 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 as well. My mother-in-law said that this child found that women in this study had to perform income- (pointed out her two-year old son), was too thin generating activities for an average of six hours per day when he was an infant, although I had already given in informal sectors. Most of these activities took place my breast milk to him. Therefore she said to me that away from their homes. Therefore, it would likely be dif- I should give him other foods as he was three months ficult to breastfeed during their absence from home. This old.” (Mother in Tögideu) was usually followed by a decline of breastfeeding fre- quency and, as previously stated, a decrease in breast Infrequent and brief feeds are commonly practiced milk production and, ultimately, cessation of breastfeed- among mothers in the study area (personal communica- ing. However, such constraints can be prevented if the tion with Health and Nutrition Officers CWS Nias). mothers have proper information on how to maintain These two factors combined were likely to be main con- milk production while separated from the baby, and how tributors to low breast milk production. This ‘insuffi- to compensate for the absence with more frequent cient breast milk syndrome’ has led to the belief that breastfeeds when mother and child are together. A six mother’s milk could not provide sufficient nutrients for hour separation is not an insurmountable barrier to the infants. Thus, most of the mothers in the study area exclusive breastfeeding. believed that a six month period of exclusive breastfeed- We also found several cultural factors influencing the ing could endanger the health and nutritional status of decision to cease breastfeeding. In our study area, the their young children. Indeed, this would be the case, if perception that prolonged breastfeeding would interfere babies were not fed frequently enough. with the child’s growth is widespread. Several mothers Brief feeds are actually very common in some regions believed that children who breastfed until the age of two where mothers are constantly active doing manual agri- years or beyond would favor consuming breast milk cultural work or gathering water or fuel. When these instead of family foods (n = 23). They believed that the mothers carry their babies with them (mostly on their child’s daily nutrient intake would not meet the recom- backs), they may compensate for the short feeds by a mended levels if consumption of home-based family more frequent feeding pattern. food was too low, and this would lead to the impaired In addition to the constraints identified above, we sur- growth of children (personal communications with sev- mise that nutrition education on Nias Island might not eral caregivers). We argue that the concern that children be optimal with regard to promoting appropriate breast- will not eat family foods properly if they are still feeding practices, and might be contributing to the low breastfed is essentially a child-rearing issue. Parents can prevalence of exclusive breastfeeding in the first six and should set reasonable limits on fulfilling children’s months in our study area. Based on Agampodi et al. consumption wishes beyond infancy. Parents need to [30], a major determinant of exclusive breastfeeding understand that the way feeding is organized is a man- practices is the health care provider’s knowledge about, agement question, and for optimal infant feeding the attitudes towards, and skills for promoting exclusive consumption of family foods should take place alongside breastfeeding. Therefore, we speculate that insufficient of continued breastfeeding during a child’sfirst two breastfeeding-related knowledge among health personnel years. and community workers may have reinforced mothers’ The belief that pregnant women should not breastfeed and families’ perceptions that have led to the low preva- their children was also a factor hindering the practice of lence of exclusive breastfeeding rates in our study area. breastfeeding during pregnancy (n = 15). According to With reference to communication to Health and Nutri- Nias culture, breastfeeding by a pregnant mother could tion Officers of CWS Nias, it may, for example, be that harm the fetus because it would decrease the fetus’ food the policy change of 2004 that adjusted the recommen- intake (personal communication with traditional healers dations for exclusive breastfeeding from “four months” in Sirombu, Nias). They also claimed that a pregnant to “six months” had not reached the grass roots level of mother who persisted in breastfeeding would deliver a public health staff on Nias Island - even almost a decade thin (afuo), sickly (mofökhö-fökhö), and feeble-minded after this policy change. (bodo) newborn baby. Therefore, most of the pregnant mothers in our study area did not breastfeed their Breastfeeding prevalence at admission young children. Considering that short birth spacing Breastfeeding prevalence among respondents was low at was commonly found in the study area, a new preg- admission into the study program for mildly wasted chil- nancy would lead to a decision to wean too early. This dren on Nias Island. One of the reasons was probably probably contributed to the low breastfeeding rate in related to the high proportion of children who were ≥ 24 our study. The belief that a mother who is ill should not breast- months (75%). Another reason was presumably related to feed her child was widespread in the study area. the heavy workloads of mothers in the study area. We Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 8 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 According to local beliefs, the illness of a mother is duration of exclusive breastfeeding, and the time to transmitted to the breastfed child through breast milk. introduce complementary feeding [15], as was also Therefore, some mothers in our study area did not observed by Aubel in the Grandmother Project [36]. breastfeed their children when they were ill (n =9). In Therefore any interventions aimed at improving young this situation, mothers preferred to provide family foods child feeding practices, particularly infant feeding beha- to the young children and halted breastfeeding during viors, should also target paternal grandmothers or part- the illness. Unfortunately, the elimination of breastfeed- ners of pregnant women, and the families of newborn infants, especially those members who play an important ing practices affects the breast milk production. A role in caring for and feeding young children. Grand- decreased breast milk supply was usually followed by breastfeeding cessation. This may also have contributed mothers, who were reported in our study to have a to the low breastfeeding prevalence in our study area. negative influence on breastfeeding, should be included in programs for breastfeeding promotion. Other target The importance of appropriate educational programs groups such as community workers, health professionals, Bearing in mind that the protective effect of breastfeed- and traditional birth attendants should also be given the ing is especially significant in populations with high necessary guidance, appropriate training, and support infant mortality, low literacy, poor sanitation facilities, with respect to breastfeeding promotion. poor nutritional status and generally low economic sta- tus [23], accurate information on the importance of Conclusion early initiation of breastfeeding, six months of exclusive In summary, the present study revealed suboptimal breastfeeding, and continued breastfeeding after the infant child feeding practices among the mothers of introduction of complementary foods would be particu- mildly wasted children in the study area on Nias Island, larly important for our respondents in this Nias study Indonesia. Thus, appropriate educational interventions who likely faced similar living conditions. Therefore, the on breastfeeding and complementary feeding are impor- promotion of correct breastfeeding practices should be tant in order to improve existing infant feeding prac- high on the agenda for any health-nutrition activities tices, as well as reduce the risk of malnutrition in young aimed to improve the well-being of young children on children. These educational strategies should focus par- Nias Island. ticularly on counteracting various myths related to It is also important to motivate mothers to practice infant feeding practices in the area targeted. To promote exclusive breastfeeding for six months with continued breastfeeding practices, it is vital to improve the coun- breastfeeding until two years or beyond, as well as intro- seling skills of community workers, as well as related ducing timely complementary feeding (six months), breastfeeding campaign actors in the study area. More- since these are high-priority infant feeding indicators for over, breastfeeding promotion in the community should child survival [35]. target not only maternal caregivers, but also other family Appropriate infant feeding promotion would help pre- members, particularly husbands and paternal grand- vent faulty feeding practices, such as the provision of mothers, taking into account the social and cultural pre-lacteal and supplementary foods (liquids) and too situation on Nias Island. early introduction of complementary foods. These inap- propriate infant feeding practices increase the risk of ill- Acknowledgements ness, malnutrition, and even death among infants and The authors gratefully acknowledge financial and in kind support from Neys- young children [13]. van Hoogstraten Foundation, Eiselen Foundation, DSM Nutritional Products, and CWS Indonesia. We are also greatly obliged to the cooperation of all Special attention to appropriate breastfeeding and voluntary workers, women and their children in the intervention area on complementary feeding interventions should be given to Nias Island. the mothers/caregivers of young infants of the ages Author details most likely to be affected by malnutrition. This suscepti- Institute for Social Sciences in Agriculture, Center Gender and Nutrition ble period is when young infants are introduced to (430b), University Hohenheim, Fruwirthstrasse 14-16, 70593 Stuttgart, foods and liquids other than breast milk. Focusing edu- Germany. The European Institute for Breastfeeding and Lactation, Kramsach, Austria. Faculty of Medicine, Study Program Nutrition, University of cational programs on this target group is likely to be Brawijaya, Malang, Indonesia. Church World Service, Jakarta, Indonesia. 5 6 more cost-effective than interventions that include a Church World Service, New York, USA. (Former) SEAMEO-TROPMED wider range of mothers/caregivers [13]. Regional Centre for Community Nutrition, Jakarta, Indonesia. Institute for Biological Chemistry and Nutrition, University Hohenheim, Stuttgart, Our qualitative assessments also found that the sup- Germany. port of family members was an important influencing factor for improving infant feeding practices in the Authors’ contributions DAI and VS designed/implemented the study and drafted the manuscript; study area. We learned that paternal grandmothers have DAI, RCP, NNW and RVP organized and supervised the study in the field; EH, great influence on infant/child feeding decisions, such as Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 9 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 MAB, JS, SH, VH, HKB and ACB helped with the study design, gave valuable 21. Alemayehu T, Haidar J, Habte D: Determinants of exclusive breastfeeding comments and contributed to the final version of the manuscript. All practices in Ethiopia. The Ethiopian Journal of Health Development 2009, authors read and approved the final manuscript. 23(1):12-18. 22. Getahun Z, Scherbaum V, Taffese Y, Teshome B, Biesalski HK: Breastfeeding Competing interests in Tigray and Gonder, Ethiopia, with special reference to exclusive/ The authors declare that they have no competing interests. almost exclusive breastfeeding beyond six months. Breastfeeding Review 2004, 12(3):8-16. Received: 2 August 2011 Accepted: 21 March 2012 23. Mihrshahi S, Ichikawa N, Shuaib M, Oddy W, Ampon R, Dibley MJ, Published: 21 March 2012 Kabir AKMI, Peat JK: Prevalence of exclusive breastfeeding in Bangladesh and its association with diarrhoea and acute respiratory infection: results of the Multiple Indicator Cluster Survey 2003. Journal of Health, References Population and Nutrition 2007, 25(2):195-204. 1. Kumar D, Goel NK, Mittal PC, Misra P: Influence of infant-feeding practice 24. Shirima R, Greiner T, Kylberg E, Gebre-Medhin M: Exclusive breast-feeding on nutritional status of under-five children. Indian Journal of Paediatrics is rarely practised in rural and urban Morogoro, Tanzania. Public Health 2006, 73:417-422. Nutrition 2001, 4(2):147-154. 2. Kimani-Murage EW, Madise NJ, Fotso JC, Kyobutungi C, Mutua MK, 25. McKenna KM, Shankar RT: The practice of prelacteal feeding to newborns Gitau TM, Yatich N: Patterns and determinants of breastfeeding and among Hindu and Muslim families. Journal of Midwifery and Women’s complementary feeding practices in urban informal settlements, Nairobi, Health 2009, 54(1):78-81. Kenya. BMC Public Health 2011, 11:396. 26. Pérez-Escamilla R, Segura-Millán S, Canahuati J, Allen H: Prelacteal feeds 3. Waiswa P, Peterson S, Tomson G, Pariyo GW: Poor newborn care practices are negatively associated with breast-feeding outcomes in Honduras. - a population based survey in eastern Uganda. BMC Pregnancy Childbirth Journal of Nutrition 1996, 126(11):2765-2773. 2010, 10:9. 27. UNICEF: The baby-friendly hospital initiative: revised and updated 4. Agudo YC, Jones AD, Berti PR, Macias SL: Breastfeeding, complementary materials 2006.[http://www.unicef.org/nutrition/index_24850.html]. feeding practices and childhood malnutrition in the Bolivien Andes. 28. Akuse RM, Obinya EA: Why healthcare workers give prelacteal feeds. Archivos Latinoamericanos de Nutricion 2010, 60(1):7-14. European Journal of Clinical Nutrition 2002, 56(8):729-734. 5. Dibley MJ, Senarath U, Agho KE: Infant and young child feeding 29. Tatone-Tokuda F, Dubois L, Girard M: Psychosocial determinants of the indicators across nine East and Southeast Asian countries: an analysis of early introduction of complementary foods. Health Education and National Survey Data 2000-2005. Public Health Nutrition 2010, Behaviour 2009, 36(2):302-320. 13(9):1296-1303. 30. Agampodi SB, Agampodi TC, Piyaseeli UK: Breastfeeding practices in a 6. The United Nations Children’s Fund (UNICEF): The state of the world’s public health field practice area in Sri Lanka: a survival analysis. children 2010: Celebrating 20 years of the convention on the rights of the child International Breastfeeding Journal 2007, 2:13. [http://www.unicef.org/rightsite/sowc/]. 31. Xu F, Binns C, Lee A, Wang Y, Xu B: Introduction of complementary foods 7. Horta BL, Bahl R, Martines JC, Victora CG: Evidence on the long-term to infants within the first six months postpartum in Xinjiang, PR China. effects of breastfeeding: systematic reviews and meta-analyses1.[http:// Asia Pacific Journal of Clinical Nutrition 2007, 16(Suppl 1):462-466. whqlibdoc.who.int/publications/2007/9789241595230_eng.pdf]. 32. Gribble KD, McGrath M, MacLaine A, Lhotska L: Supporting breastfeeding 8. Van Rossum CTM, Büchner FL, Hoekstra J: Quantification of health effects of in emergencies: protecting women’s reproductive rights and maternal breastfeeding: Review of the literature and model simulation: RIVM report and infant health. Disasters 2011, 35:720-738. 350040001/2005 Bilthoven: RIVM; 2006. 33. Mulder-Baalbergen W, Sperling G: Säuglingsernährung in akuten 9. Arenz S, Rückerl R, Koletzko B, von Kries R: Breastfeeding and childhood Krisensituationen. In Stillen: frühkindliche Ernährung und reproduktive obesity - a systematic review. International Journal of Obesity and Related Gesundheit. Edited by: Scherbaum V, Perl FM, Kretschmer U. Köln: Deutscher Metabolic Disorders 2004, 28:1247-1256. Ärzte-Verlag; 2003:160. 10. WHO Collaborative Study Team on the Role of Breastfeeding on the 34. WHO/FAO: Safe preparation, storage and handling of powdered infant Prevention of Infant Mortality: Effect of breastfeeding on infant and child formula: guidelines.[http://www.who.int/foodsafety/publications/micro/ mortality due to infectious diseases in less developed countries: a pif2007/en/]. pooled analysis [abstract]. The Lancet 2000, 355:451-455. 35. WHO/UNICEF: Child survival survey-based indicators: report of a UNICEF/ 11. Jones G, Stekete RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival WHO meeting in the WHO/UNICEF meeting, June 17-18, 2004; New Study Group: How many child deaths can we prevent this year? The York.[http://www.emro.who.int/CAH/pdf/cah_05_02.pdf]. Lancet 2003, 362:65-71. 36. The Grandmother Project, USAID, IYCN: The roles and influence of 12. World Health Organization: Infant and young child feeding.[http://www. grandmothers and men: evidence supporting a family-focuses approach to wpro.who.int/internet/resources.ashx/CHD/docs/IYCF_model_web.pdf]. optimal infant and young child nutrition Washington, DC: IYCN; 2011. 13. Breastfeeding Promotion Network India (BPNI): Faulty feeding practices and malnutrition.[http://www.bpni.org/Article/faultyfeeding.asp]. doi:10.1186/1746-4358-7-3 14. WHO: Measuring change in nutritional status Geneva: World Health Cite this article as: Inayati et al.: Infant feeding practices among mildly Organization; 1983. wasted children: a retrospective study on Nias Island, Indonesia. 15. Inayati DA: Nutritional interventions among mildly wasted children on Nias International Breastfeeding Journal 2012 7:3. Island, Indonesia: impact on children’s nutritional status and knowledge- practice of caregivers. PhD thesis University of Hohenheim: Institute for Social Sciences in Agriculture, Center of Gender and Nutrition; 2011. 16. Senarath U, Dibley MJ, Agho KE: Breastfeeding practices and associated Submit your next manuscript to BioMed Central factors among children under 24 months of age in Timor-Leste. European Journal of Clinical Nutrition 2007, 61:387-397. and take full advantage of: 17. Dakshayani B, Gangadhar MR: Breast feeding practices among the Happikis: a tribal population of Mysore district, Karnataka. Ethno-Medicine • Convenient online submission 2008, 2:127-129. • Thorough peer review 18. Yesildal N, Aytar G, Kocabay K, Mayda AS, Dagli SC, Bahcebasi T: Breastfeeding practices in Duzce, Turkey. Journal of Human Lactation • No space constraints or color figure charges 2008, 24:393-400. • Immediate publication on acceptance 19. Oommen A, Vatsa M, Paul VK, Aggarwal R: Breastfeeding practices of • Inclusion in PubMed, CAS, Scopus and Google Scholar urban and rural mothers. Indian Pediatrics 2009, 46(10):891-894. 20. Kishore MSS, Kumar P, Aggarwal AK: Breastfeeding knowledge and • Research which is freely available for redistribution practices amongst mothers in a rural population of North India: a community-based study. Journal of Tropical Pediatrics 2009, 55(3):183-188. Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Breastfeeding Journal Springer Journals

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Springer Journals
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Copyright © 2012 by Inayati et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Maternal and Child Health
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1746-4358
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22436662
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Abstract

Background: This study investigated the infant feeding practices of participating mothers who were recruited into a research project aimed at improving the nutritional status of mildly wasted children (< -1.0 to ≥ -1.5 Weight-for- Height Z-scores) aged ≥ 6 to < 60 months on Nias Island, Indonesia. Methods: Cross-sectional, questionnaire-based interview of mothers of the index children (n = 215) who were admitted to the community program for mildly wasted children in the study area. Four focus groups and twenty in-depth interviews were conducted to explore further information on infant feeding practices in the study area. Results: Retrospective results indicated that 6% of the mothers never breastfed. Fifty two percent of mothers initiated breastfeeding within six hours of birth, but 17% discarded colostrum. Exclusive breastfeeding until 6 months of age was practiced by 12%. Seventy-four percent of the mothers offered supplementary liquids besides breast milk within the first 7 days of life, and 14% of infants received these supplementary liquids from 7 days onwards until 6 months of age. Moreover, 79% of the infants were given complementary foods (solid, semi-solid, or soft foods) before 6 months of age. About 9% of the children were breastfed at least two years. Less than one in five of the mildly wasted children (19%) were breastfed on admission to the community program. Qualitative assessments found that inappropriate infant feeding practices were strongly influenced by traditional beliefs of the mothers and paternal grandmothers in the study areas. Conclusion: Generally, suboptimal infant feeding was widely practiced among mothers of mildly wasted children in the study area on Nias Island, Indonesia. To promote breastfeeding practices among mothers on Nias Island, appropriate nutrition training for community workers and health-nutrition officers is needed to improve relevant counseling skills. In addition, encouraging public nutrition education that promotes breastfeeding, taking into account social-cultural factors such as the influence of paternal grandmothers on infant feeding practice, is needed. Keywords: Breastfeeding, Complementary foods, Infant feeding, Wasted children, Nias Island Background in communities around the world [1-5]. Nationwide data Delayed breastfeeding initiation, colostrum deprivation, in Indonesia has shown that only 39% of infants experi- supplementary feeding of breast milk substitutes, early ence early initiation of breastfeeding (within one hour introduction of complementary feeding, and incorrect after birth) and 32% are exclusively breastfed for less weaning from breast milk are commonly found practices than six months [6]. Seventy-five percent of children aged 6 to 9 months were continuing to be breastfed and received complementary foods [6]. A prior survey by the * Correspondence: [email protected] Church World Service (CWS) on Nias Island, North Institute for Social Sciences in Agriculture, Center Gender and Nutrition (430b), University Hohenheim, Fruwirthstrasse 14-16, 70593 Stuttgart, Sumatra Province documented that solid foods were Germany introduced as early as 3 months and appropriate Full list of author information is available at the end of the article © 2012 Inayati et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 2 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 breastfeeding practices were uncommon (CWS Indone- or milk from a wet nurse) and nothing else, not even sia unpublished report). water, with the exception of prescribed medicines and It is well known that breastfeeding influences a child’s vitamin supplements [12]. Timely breastfeeding initia- health positively and improves nutritional status [7-9]. A tion is referred to as the start of breastfeeding within meta-analysis from three developing countries showed one hour after delivery [12]. The discontinuation of that infants who were not breastfed had a six-fold breastfeeding before six months is defined as ‘early’ dis- greater risk of dying from infectious diseases within the continuation of breastfeeding according to the breast- first two months of life than those who were breastfed feeding recommendations of the Ministry of Health, [10]. Six months of exclusive breastfeeding and contin- Republic of Indonesia. ued breastfeeding in the first year of life could also pre- vent 1.3 million child deaths worldwide according to Data collection systematic reviews from the Bellagio Child Survival The structured questionnaire used for interviewing was Study Group [11]. In addition, incorrect infant feeding pre-tested for cultural sensitivity before data collection. practices pose significant risks for malnutrition among The questionnaire forms were completed during face- children under the age of five [1,12,13]. to-face interviews with the mothers. Data collected To date, no data has been collected describing the included demographic and anthropometric variables, infant feeding patterns among mothers of mildly wasted infant feeding practices and history. children on Nias Island. This Nias study tried to assess Qualitative data assessments were performed to the history of infant feeding practices among respon- explore further information on infant feeding practices dents who were recruited into the community program in the study area. The data were collected in the course for mildly wasted children on Nias Island. In addition, of four focus group interviews, and during individual in- the study tried to determine the need for enhanced edu- depth interviews. Focus group interviews were con- cational intervention to improve the infant feeding situa- ducted in four villages in the study area (n =23).In tion there. Data were collected via a structured addition, twenty in-depth interviews were done with questionnaire that was completed in face-to-face inter- selected caregivers whose children were recruited into views as well as in focus group discussions. the study. A structured questionnaire was pre-tested prior to the study to improve comprehension. To over- Methods come the possible cultural, literacy, and language bar- Study setting and population riers, one experienced health and nutrition officer of the The study was conducted from October 2007 to Sep- implementing partner (with similar ethnicity) was pre- sent during the qualitative data assessments. With tember 2008 in the Church World Service (CWS) pro- ject area in Gunung Sitoli, Sirombu, and Mandrehe respect to focus group interviews, the moderators were Districts, Nias Island, North Sumatra Province, Indone- trained in data collection techniques prior to the quali- sia. A total of 215 mothers of mildly wasted children (< tative data assessments. -1.0 to ≥ -1.5 Weight-for-Height-Z-scores, according to WHO/NCHS reference data [14]) aged ≥ 6to< 60 Data analysis months participated in the study, which aimed at Data were coded and analyzed using the PASW/SPSS improving the nutritional status of children under five package version 19.0 (SPSS Inc., Chicago, IL, USA). years of age in this community [15]. Values were presented in percentages and means (± All mothers were interviewed at admission and were standard deviation). Qualitative data was audio taped informed about the purpose of the study. The interviews and transcribed verbatim by an experienced transcriber. were conducted by health-nutrition officers of the Interviewers and researchers reviewed the transcripts at implementing partners (CWS) who had attended a two- leastoncetoconfirm theaccuracyof the transcribed day practical training course on interview skills prior to statements. The data were further evaluated via thematic the actual data collection. Informed consent was sought analysis and coded for themes. prior to the interview, following the protocols set by the 1995 Helsinki Declaration, as revised in Edinburgh 2000. Results The study was approved by the Ethical Committee of Socio-demographic characteristics the Faculty of Medicine, University of Brawijaya (Nr. 25/ Two hundred and fifteen mothers and their children, PEPK/VIII/2007). assessed as mildly wasted, were eligible for further ana- lysis. Table 1 shows selected socio-demographic charac- Breastfeeding definitions teristics of the study population. Of 215 eligible Exclusive breastfeeding is defined as an infant being fed children, approximately 44% of those admitted to the solely breast milk (including his mother’s expressed milk study were girls. The highest proportion (28%) of them Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 3 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 Table 1 Selected characteristics of the study population The practice of giving early supplementary liquids was on Nias Island (n = 215) also frequently found in the study area. Seventy-four Frequency percent of mothers reported that they introduced liquid (%) foods besides breast milk to their infants during the first Female children, n (%) 95 (44.2) seven days of life (data not shown). Another 14% of Age group (months), n (%) infants were introduced to supplementary liquids 6 - < 12 13 (6.0) between ≥ 8 days and < 6 months. Infant formula (32%) ≥ 12 - < 24 40 (18.6) and tea (26%) were the preferred supplementary liquids ≥ 24 - < 36 61 (28.4) mentioned by the mothers in the study area. ≥ 36 - < 48 42 (19.5) Although WHO/UNICEF recommends exclusive ≥ 48-60 59 (27.4) breastfeeding for the first six months of life, only 12% of Weight-for-Height-z-score (mean ± SD) -1.3 ± 0.1 mildly wasted children (n = 25) in the study area were Height-for Age-z-score (mean ± SD) -1.5 ± 1.5 exclusively breastfed during the first six months of their Weight-for-Age-z-score (mean ± SD) -1.9 ± 0.8 lives. Age group (< 30 y), n (%) Seventy-nine percent (n = 169) of the mothers intro- Mothers 140 (65.1) duced complementary foods (solid, semi-solid or soft Fathers 89 (41.4) foods) earlier than the international recommendation of Occupation (farmer), n(%) 6 months (Figure 2). One hundred and forty-four out of Mothers 149 (69.3) 215 caregivers (67%) had already introduced comple- Fathers 122 (56.7) mentary foods before the children were four months Education of caregiver (≥ 6y), n(%) old. Five percent of the respondents (n = 10) even Mothers 80 (37.2) offered complementary foods when the children were Fathers 123 (57.2) less than one month old. Only 12% of the mothers Paternal grandmothers 99 (46.0) introduced complementary foods to their children after Household asset: ownership of TV, n(%) 54 (25.1) six months of age. Rice porridge (n = 138), milk por- Time use for income generating activities (mean ± 6.4 ± 2.6 ridge (n = 31), boiled steamed rice (n = 30), fruits (n = SD) 7), and commercially prepared baby foods (n =6)were Time use for child caring (mean ± SD) 2.1 ± 1.3 commonly reported as the first foods given to the babies in the study area. was found to be between ≥ 24 to < 36 months. The With respect to the reported duration of breastfeed- ing, most mothers (30%) breastfed their children for a average Weight-for-Height (WHZ) score was -1.3 ± 0.1, total of 6 to 12 months (n = 49), followed by 25% and whereas the average Height-for-Age(HAZ) scorewas 24% who breastfed for ≥ 4 and < 6 months and ≥ 12 -1.5 ± 1.5 and Weight-for-Age (WAZ) was -1.9 ± 0.8. and < 24 months respectively. Thirteen mothers stopped Themajorityofthe mothers(65%) were under30 breastfeeding before the babies were four months old, years old, had less than six years of schooling (63%), and but we also found that 16 respondents continued breast- worked mainly as farmers (69%). Mothers were involved feeding for more than two years (Table 2). in income generating activities for an average of six hours per day, while two hours were dedicated to child care activities. Discussion All families selected for analysis comprised two-parent Breastfeeding initiation households. More than 40% of the fathers were < 30 In our study on Nias, we found that more than half of years and worked in the agricultural sector (57%). the mothers (52%) initiated breastfeeding (la femenu)in Fathers had the best educational level (57% of them the first hour after delivery. In total, 72% of the mothers went to school for more than six years), followed by breastfed their newborns in the first six hours after paternal grandmothers (46%), and mothers (37%). baby’s birth This finding is in line with previous studies The majority of respondent households did not have a in Timor Leste, India, and Turkey [16-18]. However, television (75%). 28% of the Nias mothers initiated breastfeeding six hours after birth or even later, and 17% discarded the Infant feeding practices at admission time colostrum due to local traditional beliefs similar to the Almost 48% of the mothers did not start to breastfeed ones in the study in India [19,20]. Reasons given for not their babies within the first hour after delivery, as feeding colostrum to newborns included the traditional recommended by WHO/UNICEF. However, the major- belief that colostrum was “dirty (n = 24), cheesy (n = ity of respondents (72%) initiated breastfeeding within 14), and indigestible (n =8)” and that “children will suf- the first six hours after birth (Figure 1). fer from stomach ache/afökhö talu (n = 21)”, “children Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 4 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 Figure 1 Time of breastfeeding initiation after birth among respondents Six percent (n = 12) of the children were not breastfed at all. According to the mothers, reasons for not offering breast milk to their children immediately after delivery included “the breast milk did not come out due to inverted nipples (n =4)”, “mother was suffering from sore nipples after childbirth (n =2)”, “child did not want to suck the nipples (n =4)”, and “mother was sick after childbirth (n =2)”. As a substitute for colostrum, mothers gave infant formula (n = 4), sugar water (n = 7) or sweet tea (n = 1) after childbirth. In addition to feeding breast milk substitutes, these mothers introduced complementary foods very early (≤ 1 month of age) will get illnesses such as fever/mofa’aukhu (n = 15)”, and mature milk was believed to be ‘clean’ maternal milk. “children will be stupid/bodo (n =4)”. Colostrum was considered by some mothers to be The notion that “colostrum is dirty” (n = 24) is likely ‘cheesy (oŵoyu)’ breast milk that had been produced late due to the yellowish color of colostrum that is much in the mother’s pregnancy (n = 14) and had no nutri- different from the whitish color of mature mother’s tional value (n = 10). Colostrum was also believed to milk. The yellow color of colostrum was identified with have a bitter taste/afeto (n = 12). Thus several mothers ‘dirty (ta’unö)’ breast milk, while the white color of considered colostrum to be an inappropriate food for Figure 2 Age of introducing solid, semi-solid or soft foods among mothers of mildly wasted children (n = 215) To determine the point prevalence of breastfeeding, mothers were asked whether they had still been breastfeeding their children in the last 24 hours before admission (Table 2). The majority of children in the study area were no longer breastfed at the time of admission (76%). The main reasons for discontinuing breastfeeding included: child was too old to be breastfed, breast refusal, a new pregnancy, infant or maternal illness, as well as decreased breast milk production. Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 5 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 Table 2 Breastfeeding prevalence at admission time (n = 37) and infant formula (n = 25) were the two most among mothers of mildly wasted children (n = 215) preferred pre-lacteal liquids mentioned by the mothers. n = 215 Several mothers believed that providing pre-lacteal liquids couldhelpthe newborns to resisthunger (n = Continuing breastfeeding, n (%) 40 (18.6%) 30). They perceived that because of the process of child- Age of children (months) birth, the newborns experience fatigue, which then leads ≥ 6 - < 12 5 out of 13 to feelings of hunger. Therefore, supplementary feeding ≥ 12 - < 24 17 out of 40 serves the perception that this practice reduces infants’ ≥ 24 - < 60 18 out of hunger in the first hours of their life. Stopped breastfeeding, n (%) 163 (75.8%) Although colostrum is enough to sustain the nutri- tional needs of newborn babies without any additional Reported duration of breastfeeding practice in months n n = 163 (%) foods [12], this concept was not widely known in the < 4 13 (7.8%) study area. Giving pre-lacteal foods (e.g. formula milk or ≥ 4 - < 6 41 (25.2%) anything else other than breast milk) delays the produc- ≥ 6 - < 12 49 (30.1%) tion of breast milk [25,26]. If infants consume pre-lac- ≥ 12 - < 24 39 (23.9%) teal foods or supplementary foods, this interferes with ≥ 24 16 (9.9%) suckling at the breast, the release of prolactin and, ulti- Did not remember breastfeeding duration 5 (3.1%) mately, the production of the mother’s milk [12]. This Never breastfed, n (%) 12 (5.6%) leads to lower breast milk production and a shorter per- iod of breastfeeding [27,28]. Pre-lacteal foods are often a source of newborn infections and diarrhea [12,17]. The the newborn and believed it would be harmful to the delay of breastfeeding initiation and giving pre-lacteal infant’s health. feeds creates a vicious cycle. The practice of pre-lacteal feeding delays the initiation of breastfeeding and the “According to my mother-in-law and other senior delay in initiating breastfeeding promotes further pre- female relatives, colostrum is not a healthy food for lacteal feeding. the newborns. This first milk is dirty and cheesy. If it This Nias study found that three out of four children is given to the newborn, my infant will suffer from received supplementary feeding (liquids) in the first stomach ache . . .” (Mother in Bawadesolo) seven days of their lives. The common reason for giving supplementary feeding in the study area was perceived breast milk insufficiency (n = 22), which was likely due The practice of discarding colostrum is strongly to the delay of breastfeeding initiation. Bearing in mind rooted in the study area. We argue that the strong role that the frequency and the duration of breastfeeding are of senior family members, particularly senior women important factors in stimulating breast milk production, such as the paternal grandmother, in prohibiting the it is not surprising that incorrect breastfeeding practice consumption of colostrum for newborns has sustained such as providing supplementary foods results in insuffi- this custom, and that it has been carried out for genera- cient production of breast milk. tions in the study area. It is known that early initiation of breastfeeding will Introduction of complementary foods (solid, semi-solid or result in better establishment of breastfeeding practices, soft foods) including longer duration of breastfeeding. This practice The appropriate time for introducing complementary also ensures that newborns receive food with high nutri- foods and the types of foods are crucial factors to be tional value at the beginning of their lives. Early breast- feeding initiation can protect the newborn from considered in appropriate infant and child feeding prac- potentially harmful pre-lacteal feeding practices which tices. According to Agudo et al. [4], findings from sev- deprive the infant of the important immune-protective eral studies showed that the majority of mothers in properties of colostrum [12]. developing countries initiated complementary feeding too early. Other studies have had similar findings Practice of pre-lacteal feeding and use of supplementary [29-31]. Our study also revealed that early introduction liquids of solid and semi-solid foods was common in the study Wide use of pre-lacteal foods has been identified from area. previous studies in India, Ethiopia, Bangladesh, and Tan- Most of our respondents preferred to introduce com- zania [17,20-24]. The practice of pre-lacteal feeding was plementary foods (solid, semi-solid, or soft food) when also common in our study area (personal information the children were one to four months old. This was in with Health and Nutrition officers CWS). Sugar water line with the results of our qualitative assessments that Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 6 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 found that the majority of mothers believed that an supplementary food in addition to breastfeeding within appropriate time for introducing complementary foods six months (13%), or to fully replace breast milk (2%) in was between one and four months (n = 32). the study area. Some mothers perceived that infant for- A perceived decline in the production of breast milk mula had highly valuable nutrients that were as good as, was the main reason mentioned for early introduction of or even better than breast milk (n =10).Therefore,they complementary foods in the study area (n =30).Practice believed that if the household had the financial means, of pre-lacteal feeding, skepticism about the sufficiency of formula should be provided to the babies. However, their own breast milk production, inappropriate time of according to Gribble et al. [32] and Mulder-Baalbergen et introduction of complementary foods, as well as infre- al. [33], several considerations should be taken into quent and too short duration of breastfeeds, were appar- account when providing infant formula at the household ently responsible for the decline in the maternal milk level, particularly in emergency situations. These include supply. On the other hand, perceived insufficient breast the availability of clean water, energy for heating/boiling milk production also led to too early initiation of comple- water and sterilizing bottles and other equipment, house- mentary feeding. In both situations, mothers believed hold finances as well as the ability of caregivers to pre- that their child’s crying was a signal of insufficient food pare infant formula correctly according to the intake. Thus, the provision of complementary foods manufacturer’s instruction [32,33]. These requirements seemed to them to be the only way to satisfy the child. appeared to be very difficult for respondents in our study area to meet. “Mothers in this area have usually introduced com- As stated in WHO/FAO guidelines [34], preparing plementary foods when infants are four months old. infant formula according to the manufacturer’sinstruc- However, they will provide complementary foods ear- tions is still not sufficient and safe because of the inherent lier if the child still cries although breast milk has bacterial contamination in many powdered formulas. already been given” (Mother in Tugala Gawu) Manufacturers do not usually give accurate information about an adequate temperature for the water to be mixed The opinions of senior female members of the family, with the powdered formula. In order to destroy the bac- especially the paternal grandmother (ina matua), about teria, water must be boiled and then cooled to no less than the infant’s well-being played an important role in the 70°c (between 70° and 90°C) before mixing. This was also decision of mothers to introduce solid, semi-solid, or soft not known in the study area. Accurate assessment of foods (n = 23). If an infant was considered by the female water temperature is also highly uncertain. in-law to be too ‘thin’ (afuo), a mother was likely to initi- ate complementary foods. As reported by respondents, Exclusive breastfeeding practice the decision to provide complementary foods was usually In our study area, only one out of nine mothers prac- ticed exclusive breastfeeding with their infants. This low not accompanied by maintaining breastfeeding fre- prevalence of exclusive breastfeeding has been com- quency. It is therefore not surprising that increasing sup- monly reported in studies in India, Bangladesh, Sri plemental food was associated with less breastfeeding Lanka, Turkey, and Tanzania [18,20,23,24,30]. Based on and breast milk production declined. Even worse, breast- qualitative assessment, the most common barrier to feeding was generally no longer practiced after a child practicing exclusive breastfeeding in the study area was was given complementary foods. This is a very common perceived insufficient breast milk production (n =30). pattern around the world reflecting a misunderstanding Other reasons, such as believing that the child was star- of complementary feeding (solids) as a replacement for ving (n = 15), the mother’s activity outside her home (n breastfeeding, rather than a complement to it. = 10), poor knowledge of the benefits of exclusive Early introduction of liquids and solids is unnecessary breastfeeding (n = 7), and the mother’s illness (n =7) and unwise because it can reduce the duration and fre- were also mentioned by several mothers. quency of breastfeeding [12,24], as previously observed in A mother may make a decision to add supplemental our study area. Premature introduction of complemen- fluids or soft complementary foods at too early an age if tary foods increases the risk of infant morbidity and mor- she is feeling discouraged about her milk production. If tality [12,24]. We therefore conclude that children in our a mother believes that she cannot produce a sufficient Nias studyareafaceincreased andunnecessaryhealth quantity of breast milk, she tends to decrease her breast- risks due to inappropriate infant feeding practices. feeding frequency. This will result in decreasing breast milk production. The use of infant formula Commercially produced infant formula was provided as a “IamsurethatIdid nothavesufficientbreastmilk supplementary food (liquid) in addition to breast milk production. My breast is too small and I am too thin during the first seven days of life (32%), as a Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 7 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 as well. My mother-in-law said that this child found that women in this study had to perform income- (pointed out her two-year old son), was too thin generating activities for an average of six hours per day when he was an infant, although I had already given in informal sectors. Most of these activities took place my breast milk to him. Therefore she said to me that away from their homes. Therefore, it would likely be dif- I should give him other foods as he was three months ficult to breastfeed during their absence from home. This old.” (Mother in Tögideu) was usually followed by a decline of breastfeeding fre- quency and, as previously stated, a decrease in breast Infrequent and brief feeds are commonly practiced milk production and, ultimately, cessation of breastfeed- among mothers in the study area (personal communica- ing. However, such constraints can be prevented if the tion with Health and Nutrition Officers CWS Nias). mothers have proper information on how to maintain These two factors combined were likely to be main con- milk production while separated from the baby, and how tributors to low breast milk production. This ‘insuffi- to compensate for the absence with more frequent cient breast milk syndrome’ has led to the belief that breastfeeds when mother and child are together. A six mother’s milk could not provide sufficient nutrients for hour separation is not an insurmountable barrier to the infants. Thus, most of the mothers in the study area exclusive breastfeeding. believed that a six month period of exclusive breastfeed- We also found several cultural factors influencing the ing could endanger the health and nutritional status of decision to cease breastfeeding. In our study area, the their young children. Indeed, this would be the case, if perception that prolonged breastfeeding would interfere babies were not fed frequently enough. with the child’s growth is widespread. Several mothers Brief feeds are actually very common in some regions believed that children who breastfed until the age of two where mothers are constantly active doing manual agri- years or beyond would favor consuming breast milk cultural work or gathering water or fuel. When these instead of family foods (n = 23). They believed that the mothers carry their babies with them (mostly on their child’s daily nutrient intake would not meet the recom- backs), they may compensate for the short feeds by a mended levels if consumption of home-based family more frequent feeding pattern. food was too low, and this would lead to the impaired In addition to the constraints identified above, we sur- growth of children (personal communications with sev- mise that nutrition education on Nias Island might not eral caregivers). We argue that the concern that children be optimal with regard to promoting appropriate breast- will not eat family foods properly if they are still feeding practices, and might be contributing to the low breastfed is essentially a child-rearing issue. Parents can prevalence of exclusive breastfeeding in the first six and should set reasonable limits on fulfilling children’s months in our study area. Based on Agampodi et al. consumption wishes beyond infancy. Parents need to [30], a major determinant of exclusive breastfeeding understand that the way feeding is organized is a man- practices is the health care provider’s knowledge about, agement question, and for optimal infant feeding the attitudes towards, and skills for promoting exclusive consumption of family foods should take place alongside breastfeeding. Therefore, we speculate that insufficient of continued breastfeeding during a child’sfirst two breastfeeding-related knowledge among health personnel years. and community workers may have reinforced mothers’ The belief that pregnant women should not breastfeed and families’ perceptions that have led to the low preva- their children was also a factor hindering the practice of lence of exclusive breastfeeding rates in our study area. breastfeeding during pregnancy (n = 15). According to With reference to communication to Health and Nutri- Nias culture, breastfeeding by a pregnant mother could tion Officers of CWS Nias, it may, for example, be that harm the fetus because it would decrease the fetus’ food the policy change of 2004 that adjusted the recommen- intake (personal communication with traditional healers dations for exclusive breastfeeding from “four months” in Sirombu, Nias). They also claimed that a pregnant to “six months” had not reached the grass roots level of mother who persisted in breastfeeding would deliver a public health staff on Nias Island - even almost a decade thin (afuo), sickly (mofökhö-fökhö), and feeble-minded after this policy change. (bodo) newborn baby. Therefore, most of the pregnant mothers in our study area did not breastfeed their Breastfeeding prevalence at admission young children. Considering that short birth spacing Breastfeeding prevalence among respondents was low at was commonly found in the study area, a new preg- admission into the study program for mildly wasted chil- nancy would lead to a decision to wean too early. This dren on Nias Island. One of the reasons was probably probably contributed to the low breastfeeding rate in related to the high proportion of children who were ≥ 24 our study. The belief that a mother who is ill should not breast- months (75%). Another reason was presumably related to feed her child was widespread in the study area. the heavy workloads of mothers in the study area. We Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 8 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 According to local beliefs, the illness of a mother is duration of exclusive breastfeeding, and the time to transmitted to the breastfed child through breast milk. introduce complementary feeding [15], as was also Therefore, some mothers in our study area did not observed by Aubel in the Grandmother Project [36]. breastfeed their children when they were ill (n =9). In Therefore any interventions aimed at improving young this situation, mothers preferred to provide family foods child feeding practices, particularly infant feeding beha- to the young children and halted breastfeeding during viors, should also target paternal grandmothers or part- the illness. Unfortunately, the elimination of breastfeed- ners of pregnant women, and the families of newborn infants, especially those members who play an important ing practices affects the breast milk production. A role in caring for and feeding young children. Grand- decreased breast milk supply was usually followed by breastfeeding cessation. This may also have contributed mothers, who were reported in our study to have a to the low breastfeeding prevalence in our study area. negative influence on breastfeeding, should be included in programs for breastfeeding promotion. Other target The importance of appropriate educational programs groups such as community workers, health professionals, Bearing in mind that the protective effect of breastfeed- and traditional birth attendants should also be given the ing is especially significant in populations with high necessary guidance, appropriate training, and support infant mortality, low literacy, poor sanitation facilities, with respect to breastfeeding promotion. poor nutritional status and generally low economic sta- tus [23], accurate information on the importance of Conclusion early initiation of breastfeeding, six months of exclusive In summary, the present study revealed suboptimal breastfeeding, and continued breastfeeding after the infant child feeding practices among the mothers of introduction of complementary foods would be particu- mildly wasted children in the study area on Nias Island, larly important for our respondents in this Nias study Indonesia. Thus, appropriate educational interventions who likely faced similar living conditions. Therefore, the on breastfeeding and complementary feeding are impor- promotion of correct breastfeeding practices should be tant in order to improve existing infant feeding prac- high on the agenda for any health-nutrition activities tices, as well as reduce the risk of malnutrition in young aimed to improve the well-being of young children on children. These educational strategies should focus par- Nias Island. ticularly on counteracting various myths related to It is also important to motivate mothers to practice infant feeding practices in the area targeted. To promote exclusive breastfeeding for six months with continued breastfeeding practices, it is vital to improve the coun- breastfeeding until two years or beyond, as well as intro- seling skills of community workers, as well as related ducing timely complementary feeding (six months), breastfeeding campaign actors in the study area. More- since these are high-priority infant feeding indicators for over, breastfeeding promotion in the community should child survival [35]. target not only maternal caregivers, but also other family Appropriate infant feeding promotion would help pre- members, particularly husbands and paternal grand- vent faulty feeding practices, such as the provision of mothers, taking into account the social and cultural pre-lacteal and supplementary foods (liquids) and too situation on Nias Island. early introduction of complementary foods. These inap- propriate infant feeding practices increase the risk of ill- Acknowledgements ness, malnutrition, and even death among infants and The authors gratefully acknowledge financial and in kind support from Neys- young children [13]. van Hoogstraten Foundation, Eiselen Foundation, DSM Nutritional Products, and CWS Indonesia. We are also greatly obliged to the cooperation of all Special attention to appropriate breastfeeding and voluntary workers, women and their children in the intervention area on complementary feeding interventions should be given to Nias Island. the mothers/caregivers of young infants of the ages Author details most likely to be affected by malnutrition. This suscepti- Institute for Social Sciences in Agriculture, Center Gender and Nutrition ble period is when young infants are introduced to (430b), University Hohenheim, Fruwirthstrasse 14-16, 70593 Stuttgart, foods and liquids other than breast milk. Focusing edu- Germany. The European Institute for Breastfeeding and Lactation, Kramsach, Austria. Faculty of Medicine, Study Program Nutrition, University of cational programs on this target group is likely to be Brawijaya, Malang, Indonesia. Church World Service, Jakarta, Indonesia. 5 6 more cost-effective than interventions that include a Church World Service, New York, USA. (Former) SEAMEO-TROPMED wider range of mothers/caregivers [13]. Regional Centre for Community Nutrition, Jakarta, Indonesia. Institute for Biological Chemistry and Nutrition, University Hohenheim, Stuttgart, Our qualitative assessments also found that the sup- Germany. port of family members was an important influencing factor for improving infant feeding practices in the Authors’ contributions DAI and VS designed/implemented the study and drafted the manuscript; study area. We learned that paternal grandmothers have DAI, RCP, NNW and RVP organized and supervised the study in the field; EH, great influence on infant/child feeding decisions, such as Inayati et al. International Breastfeeding Journal 2012, 7:3 Page 9 of 9 http://www.internationalbreastfeedingjournal.com/content/7/1/3 MAB, JS, SH, VH, HKB and ACB helped with the study design, gave valuable 21. Alemayehu T, Haidar J, Habte D: Determinants of exclusive breastfeeding comments and contributed to the final version of the manuscript. All practices in Ethiopia. The Ethiopian Journal of Health Development 2009, authors read and approved the final manuscript. 23(1):12-18. 22. Getahun Z, Scherbaum V, Taffese Y, Teshome B, Biesalski HK: Breastfeeding Competing interests in Tigray and Gonder, Ethiopia, with special reference to exclusive/ The authors declare that they have no competing interests. almost exclusive breastfeeding beyond six months. Breastfeeding Review 2004, 12(3):8-16. Received: 2 August 2011 Accepted: 21 March 2012 23. Mihrshahi S, Ichikawa N, Shuaib M, Oddy W, Ampon R, Dibley MJ, Published: 21 March 2012 Kabir AKMI, Peat JK: Prevalence of exclusive breastfeeding in Bangladesh and its association with diarrhoea and acute respiratory infection: results of the Multiple Indicator Cluster Survey 2003. 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Published: Mar 21, 2012

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